Provider Demographics
NPI:1770332280
Name:BANTILES, JOHVANI E
Entity type:Individual
Prefix:
First Name:JOHVANI
Middle Name:E
Last Name:BANTILES
Suffix:
Gender:X
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:720 MILL ST APT 1
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:13601-1566
Mailing Address - Country:US
Mailing Address - Phone:315-775-7649
Mailing Address - Fax:
Practice Address - Street 1:650 STATE ST
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:NY
Practice Address - Zip Code:13601-2839
Practice Address - Country:US
Practice Address - Phone:315-755-1251
Practice Address - Fax:315-291-6601
Is Sole Proprietor?:No
Enumeration Date:2024-05-16
Last Update Date:2024-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY915663163WP0807X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0807XNursing Service ProvidersRegistered NursePsychiatric/Mental Health, Child & Adolescent